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JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR.OFFICE USE: 16 ` Hazelton Ave. , ,Stockton, Cain. <br /> Telephone: (209) 466-6781 rl <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. d� 5 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date. Issued �� <br /> . (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquij <br /> County Ordinance No. .1862 and the Rules and Regulations of the San Joaquin Local, Health District. <br /> JOB ADDRESS/LOCATION 10663 Hwy. 88- See reverse for map CENSUS TRACT <br /> Owner's Name MATT WARD Phone <br /> Address .1959 Sonoma Street City Stockton <br /> Contractor's Name Goehring Pump & Irrigation, Inc. -.License # 30903.1 Phone 727-5548 <br /> TYPE OF WORK (Check) : NEW WELL '/-7 DEEPEN '/—/ RECONDITION /? DESTRUCTION /_7PUMP INSTALLATION /:/ PUMP REPAIR / / PUMP REPLACEMENT /Xy <br /> Other. j/7 -.^. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PITOTHER 0 <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL—. <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia.- of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal r <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: O� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. . .. <br /> PUMP REPLACEMENT: 1X/ State Work Done jr1sta.11 <br /> been recased. <br /> PUMP .REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health i$trict <br /> and the State of California pertaining to or regulating we11 ''construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will .furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the..well in use. The above . <br /> infor;TO <br /> ion rue to the best of. my .knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />.PRIOR G G AO A FINAL INSPECTION. <br /> SIGNEDTITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE V!J <br /> ADDITIONAL COMMENTS; ^ ^ <br /> PHASE II GROUT INSPECTION PHASE II /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 / 117V, 2M <br />